Inspection·April 16, 2025

F 0656 Regular diet, mechanical soft ground meat texture, regular thin consistency dated 03/20/25. Level of Harm - Minimal harm or potential for actual harm DNR dated 03/24/25. Residents Affected - Few Losartan Potassium oral tablet 100 MG. Give 1 tablet by mouth one time a day related to essential hypertension dated 03/21/25. Spironolactone oral tablet 25 MG. Give 1 tablet by mouth one time a day related to essential hypertension, dated 03/20/25. Occupational Therapy to evaluate and treat 3-5x/wk x 30 days . dated 04/01/25. Physical Therapy to evaluate and treat 3-5x/wk x 30 days . dated 04/02/25. ST to evaluate and treat as indicated ST clarification: Patient to receive ST 3-5x week for 4 weeks for cognition, dated 04/01/25. During an interview on 04/16/25 at 8:42 AM, the ADON stated the MDSC was responsible for the comprehensive care plans. The ADON stated she had recently started on the care plans. She stated the comprehensive care plan should include allergies, code status, diet, wounds, EBP, catheter. During an interview on 04/16/25 at 9:40 AM, the NC stated a baseline care plan was due within 48 hours of admit and a comprehensive care plan was due 7 days after the close of the MDS. She stated all pertinent care of the resident should be included on the comprehensive care plan. She stated it was important to have the care plan in place with goals and interventions to meet the resident's needs. The NC stated the MDSC was responsible for the care plans, but the MDSC was out of the facility for the day. During an interview on 04/16/25 at 2:32 PM, the ADON stated the comprehensive care plan was completed within two weeks after admission. When asked if there could be an adverse outcome for a resident if the care plan was not completed, she stated the information on the care plan could be found in other places in the medical record. A telephone interview was attempted on 04/16/25 at 3:38 PM. The MDSC did not answer the call. The recording stated unable to leave a message as the voicemail was full. Review of the facility's undated Comprehensive Care Plans policy reflected in part, :It is the policy of this facility to develop and implement a comprehensive care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Policy Explanation and compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .d. The resident's goals for admission, desired outcomes, and preferences for future discharge . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 2 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #50 & #171) of 6 residents reviewed for quality of care. Residents Affected - Few The facility failed to document weekly skin assessments for Residents #50 & #171 according to physician orders. This failure could place residents at risk of not receiving necessary medical care, and hospitalization. Findings included: Review of Resident #50's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia (progressive loss of mental abilities like memory, thinking, and reasoning, so severe that it interferes with daily life), unspecified severe protein calorie malnutrition (a condition characterized by a significant deficiency in both protein and energy intake, leading to a range of physical symptoms), muscle weakness (reduction in the ability to move your muscle, making it harder to do things like lift objects or move your body), and type 2 diabetes mellitus without complications (your body has difficulty using sugar for energy, leading to high blood sugar level). Review of Resident #50's Quarterly MDS, dated [DATE], reflected a BIMS score of 14 indicated was cognitively intact. Resident #50 Quarterly MDS also reflected he required partial/moderate assistance in the area of shower/bathe self. Review of Resident #50's care plan, dated 04/16/2025, reflected Resident #50 was care planed for occasional urinary incontinence with a goal of the resident will remain free from skin breakdown due to incontinence and brief use through the review. There was an intervention of encourage/remind and offer to assist resident to use bathroom as needed. Review of Resident #50's physician order, dated 02/09/2022, reflected weekly skin assessment with directions of every day shift every Wednesday. Review of Resident #50's Weekly Skin Assessment in his EMR, dated 04/16/2025, reflected Resident #50's Weekly Skin Assessment had not been completed for the week of 04/06/2025 - 04/12/2025. Resident #50's last skin assessment was completed on 04/03/2025 with no skin concerns noted. During an interview with Resident #50 on 04/16/2025 at 2:05 pm, Resident #50 was not aware that his weekly skin assessment had not been completed for the week of 04/06/2025 - 04/12/2025. Resident #50 stated that he did not have any skin issues. Review of Resident #171's undated face sheet reflected a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (a medical condition characterized by paralysis or weakness on one side of the body), hyperlipidemia (having too much fat in your blood), essential (primary) hypertension (high blood pressure where the cause is unknown) and muscle weakness (reduction in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 3 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 ability to move your muscle, making it harder to do things like lift objects or move your body). Level of Harm - Minimal harm or potential for actual harm Review of Resident #171's Quarterly MDS, dated [DATE], reflected a BIMS score of 13 indicated was cognitively intact. Resident #171 Quarterly MDS also reflected he required partial/moderate assistance in the areas of toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and person hygiene. Residents Affected - Few Review of Resident #171's care plan, dated 04/16/2025, reflected Resident #171 was care planed for frequent incontinence with an intervene of monitor skin per facility protocol. Review of Resident #171's physician order, dated 01/04/2025, reflected weekly skin assessment with directions of every day shift every Saturday. Review of Resident #171's Weekly Skin Assessment in his EMR, dated 04/16/2025, reflected Resident #171's Weekly Skin Assessment had not been completed for the weeks 04/02/2025 - 04/08/2025 and 04/09/2025 - 04/04/15/20250. Resident #171's last skin assessment was completed on 03/29/2025 with no skin concerns noted. During an interview with Resident #171 on 04/16/2025 at 10:35 am, Resident #171 stated that she was not sure when her skin assessment was supposed to be done. Resident #171 also stated that she had a skin assessment recently but couldn't provide a date. Resident #171 stated she did not have any skin issues or concerns. During an interview with LVN C on 04/16/2025 at 2:50 pm, LVN C she stated she was not aware that Resident #50 and Resident #171 weekly skin assessments hadn't been completed. LVN C stated it was the charge nurse's responsible for completing the skin assessment per the physician orders. LVN C stated she had been off the days the assessments were scheduled for completion. LVN C stated that if a resident doesn't receive a weekly skin assessment, they resident could have an unknown wound or sore. During an interview with the NC on 04/16/2025 at 3:10 pm, the NC stated it the charge nurse was responsible for completing the skin assessment. The NC stated every resident should be receiving a weekly skin assessment to ensure the resident doesn't have any skin breakdown or unknown wounds. The NC stated it was her expectation that skin assessments are completed per the physician orders. During an interview with the interim ADM on 04/16/2025 at 3:20 pm, the interim ADM stated skin assessments should always be followed per the physician orders. The ADM stated it was the charge nurse of the 200-hall responsibility for ensure the skin assessments were completed. The ADM stated if skin assessments weren't completed weekly then a resident could have a skin issue/wound and the facility wouldn't know. The ADM expects that all skin assessments are followed per the physician orders. Review of facility Skin Assessment policy dated 2024 reflected It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 4 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm A full body, or head to toe skin assessment will be conducted by a licensed for registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: Residents Affected - Few a. Include date and time of the assessment, your name, and position title. b. Document observation (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound d. Describe wound (measure, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 5 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure that a designated DON was providing coverage on a full time basis for one out of one facility. Residents Affected - Some The facility failed to ensure they had a DON on duty for a total of 12 days from 04/04/2025 to 04/14/2025. This failure could place residents at risk of missing assessments, interventions and care. Findings include: On 04/14/2025 at 10:30 AM an interview with the Executive Director revealed the facility does not have an active Director of Nursing employed at the facility. The ED stated that the facility has ensured a Registered Nurse is onsite at all times. The ED also reported that a Corporate Nurse was on site once a month to help with DON coverage. The ED stated that the facility uses telehealth and is available for support at all times. The ED reported the last time the DON was on site was 04/03/2025. On 04/14/2025 at 2:30 PM record review indicated that the DON was last in the facility providing DON coverage on 04/03/2025. RR indicated that for the week dated 03/30/2025 to 04/05/2025, the DON provided DON coverage for a total of 27 hours for the week. RR revealed no other DON coverage was provided on site. On 04/16/2025 at 10:01 AM an interview was conducted with CNA F, who reported being employed at the facility for 20 years. CNA F reported receiving trainings on abuse and neglect a couple of months ago. CNA F stated the trainings covered verbal, physical and mental abuse. CNA F reported receiving training on resident rights a month ago which covered the rights of residents to complain, right to choices and other rights . CNA F stated the designated DON quit and had not returned to work in two weeks. CNA F stated that they report to the charge nurse when there is an emergency. CNA F reported they would go to the ADON or administrator if there was not a DON on site. CNA F stated a negative impact not having a DON on site could cause for a resident is not having access to the DON. On 04/16/2025 at 10:30AM an interview was conducted with LVN C, who reported being employed at the facility for 1 year. LVN C reported receiving trainings on abuse and neglect in February. LVN C stated the training covered misappropriation of resident's property and reporting any abuse allegations. LVN C reported that they have received training on resident rights which is provided annually. LVN C reported that the trainings covered all of the resident's rights, decisions and safety. LVN C reported that the facility has an interim DON until the new DON starts working. LVN C stated they report to the corporate DON or the ADON in the meantime. LVN C reported the DON stopped working at the facility two weeks ago. LVN C stated in case of an emergency, they would report to whoever is on call and depending on the severity they would call the administrator. LVN C stated that if there was no DON onsite during an emergency, they would report to the ADON or the RN in charge at that time. LVN C reported that a negative impact not having a DON on site could cause a resident is they could have items missed. LVN C reported that the DON is a catch all who checks orders, checks on the residents and ensure things are being assessed and processed. LVN C stated this could impact the flow of processing with having a DON. On 04/16/2025 at 10:45AM an interview was conducted with RN G who reported being employed at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 6 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility for 3 years. RN G reported that they have received trainings on abuse and neglect last month, which covered dementia, taking good count of the resident numbers, and to be understanding of resident's behaviors. RN G reported receiving trainings on resident rights ongoing. RN G reported the training covered a major focus on dignity and making sure the residents are treated fairly . RN G reported that there is a new DON coming to the facility but may report to the ADON in the meantime. RN G reported that the previous DON stopped working at the facility two weeks ago. RN G stated that they would go to the next higher up, the ADON, in case of an emergency. RN G reported that they do not typically report to the DON during an emergency. RN G reported that a potential negative impact not having a DON on site could cause a resident is that care could potentially be impacted especially for hectic days. On 04/16/2025 at 11:15AM an interview was conducted with Nurse Consultant (NC) who reported being employed at the facility for 3 ½ years. The NC reported that they were designated the interim DON on April 4th. NC reported that they provide DON coverage whenever the ED calls and asks for support. The NC reported that for her, DON coverage looks like being available at the facility as needed and being available over the phone at all times. The NC reported that a DON should be on site at the facility as needed, not full time. The NC reported that they would handle an emergency on site, if they were off site, by calling the ED, talk to the nurses and potentially do face to face interviews/assessments over video chat as needed. The NC stated they have access to all of the residents' files and system for the facility where they can view and log reports. The NC reported as long as an RN is on site, residents should not be negatively impacted by not having a DON on site. The NC reported that they are a nurse consultant for multiple facilities. On 04/16/2025 at 12:30PM an interview was conducted with ADON who reported being employed at the facility for 4 years. ADON reported that they have received trainings on abuse and neglect this year. ADON reported that the trainings covered the definition of abuse, neglect, exploitation and the different types of abuse. ADON reported receiving trainings on resident rights this year as well that summarized a list of resident rights for choices, medications and food preferences that are available for example . The ADON reported that the designated DON is the NC. The ADON reported that the previous DON stopped working at the facility on April 3, 2025. The ADON stated that in an event of an emergency, they will call 911. The ADON stated that if there is an emergency and a DON is not on site, they will notify an RN if it requires an RN. The ADON stated that the MDS nurse develops and implements care plans as well as the ADON. The ADON stated that if there is no DON to help with care plans, that the MDS does it. The ADON also stated that medical records are responsible for ordering supplies. The ADON stated the DON is not responsible for training nurse staff. ADON denies knowing a negative impact that not having a DON on site could have on a resident. On 04/16/2025 at 1:15PM an interview was conducted with the ED, who reported being employed at the facility for 3 ½ years. ED stated that the staff would report to the NC, ED and/or and RN in case of an emergency and no DON is on site. The ED reported that if there was an emergency and the NC was not on site, it is expected that the staff talk to the RN who is on shift or call an on-call nurse. The ED stated that MDS nurse, DON and IDT team develop and implements care plans. The ED reported if the DON is not present to help develop and implement care plans, then the ADON or NC will help. ED stated that medical records is responsible for ordering supplies and equipment. The ED stated that the ED and the DON ensure that the supply closet is supplied. ED stated that Staff development nurse is responsible for training nursing staff. ED stated that there is no negative impact for residents if there is no DON on site. When the ED was asked if they were aware of the regulations on DON coverage, the ED reported that they were aware of the regulation to have a designated full time DON, but not the regulation of the DON having to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 7 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 be on site. Level of Harm - Minimal harm or potential for actual harm RR of Nursing Services and Sufficient Staff policy provided by the facility dated 2025 indicated the following: Residents Affected - Some 1. It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. 2. The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. RR of a document dated 04/06/2025 provided by the ED that included two signatures that belong to NC and ED revealed as a letter indicated the following: 1. NC will be serving as the Acting Director of Nurses (DON) for facility until incoming DON assumes the position on April 17, 2025. During this interim period, NC will be available by phone an will manage all responsibilities associated with the DON role, both onsite and offsite, in accordance with the established regulations. RR of the DON Job Description provided by the facility revealed the following expectations of a DON: 1. Ability to perform essential duties as outlined. 2. Ability to perform works tasks within the physical demand requirements as outlined. 3. Accountable for nursing compliance, excellence and delivery of resident care services in adherence with the company, local, state and federal regulations. 4. Manage nursing staff through appropriate hiring, training, evaluation, assignment and delegation of duties, within budget and resident census guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 8 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 5. Level of Harm - Minimal harm or potential for actual harm Develop and implement resident care plans in coordination with physician, medical director, nursing staff, and outside consultants. Residents Affected - Some 6. Ensure appropriate equipment supplies and resources are available to staff on a timely basis. 7. Train and develop nursing staff to achieve positive resident outcome. 8. Reliability, trustworthiness and consistency with regard to attendance is extremely important to this job. The ability to regularly and timely attend work, cooperative and politely work and deal with others, and to effectively multi-task and work in a stressful environment are also essential functions to this job. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 9 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (100/200 nurse cart) reviewed for medication storage. The facility failed to ensure an expired insulin pen was removed from the medication cart. This failure could place residents at risk of not receiving the intended therapeutic effect of the insulin. Findings included: An observation of the 100/200 nurse cart on 05/15/25 at 2:09 PM revealed an insulin pen with an open date of 03/04/25. During interview on 04/15/25 at 2:11 PM, LVN B stated he was not sure when insulin pens expired after being opened, but he would get the answer. LVN B returned and stated the insulin was good for 28 days so, the pen opened on 03/04/25 should have been removed from the cart. He stated if expired medications were administered, the resident may not have received the desired effect. During an interview on 04/16/25 at 2:32 PM, the ADON stated insulin pens were good for 28 days once opened. She stated expired medications may not be effective. During an interview on 04/16/24 at 2:42 PM, the NC stated she expected medication expirations were checked prior to administration. She stated once opened the insulin pens were good for 28-30 days. She stated the facility did not have a policy specific to insulin pens, but the pharmacy had provided a document that listed expiration dates. She stated expired insulin could be ineffective and cause blood sugars to go out of control. During an interview on 04/16/25 at 2:57, the ED stated he expected staff to follow the policies for medication administration. Review of the facility's undated Medication Administration policy reflected in part, Medications are administered by the licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .13. Identify expiration date. If expired, notify nurse manager . Review of the facility's undated Medication Storage policy revealed it did not address expired medications on the medication carts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 10 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (Resident #66) of five residents reviewed for unnecessary medications. The facility failed to indicate an adequate diagnosis for Quetiapine (an atypical antipsychotic medication used to treat schizophrenia and bipolar disorder) for Resident #66. This failure could place residents on psychoactive medications, without an adequate diagnosis, at risk for taking unnecessary medications. Findings included: Review of Resident #66's undated face sheet reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (dementia that damages the brain) - unspecified (primary diagnosis), dementia in other diseases classified elsewhere - severe - without behavioral disturbances - psychotic disturbance - mood disturbance and anxiety, essential hypertension (high blood pressure), difficulty walking, other lack of coordination, and cognitive communication deficit. Review of Resident #66's admission MDS assessment dated [DATE], Section C reflected a BIMS score of 4 indication severely impaired cognition. Section E reflected no hallucinations or delusions, he did not reject care, and he wandered 4 to 6 days during the reporting period. No other behaviors were identified. Section I reflected Progressive Neurological Conditions as his primary medical condition category. No psychiatric/mood disorders were identified. Section N reflected he was taking antipsychotic and antianxiety medications. Review of Resident #66's comprehensive care plan, initiated on 12/11/24, reflected in part: Focus: Resident takes antipsychotic and antianxiety medication. Goal: Resident will have no s/s of adverse reactions or side effects of medications through next review date. Interventions: Remind resident about not entering other residents' rooms. Advise resident and RP of need for medication and place signed consent in chart. Approach in calm manner, introduce self, explain procedure/care to be provided. Provide reassurance as needed. Do not rush. Call light in reach in room and answered promptly . Observe for side effects, adverse reaction from medication to include but not limited to: agitation, sedation, headache, sleep disturbance, EPS (movement disorder), and notify MD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 11 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Observe for targeted behaviors of agitation, combativeness, aggression. If behavior is affecting other residents, remove from common areas to calmer setting, provide diversional activity . Review of Resident #66's Order Summary Report for active orders as of 04/16/25, reflected the following orders: Residents Affected - Few Quetiapine Fumarate oral tablet 25mg. Give 1 tablet by mouth at bedtime related to Dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety written 11/25/24. Behaviors: (1)Agitation/Anger, (2)Anxiety, (3)Crying/Tearfulness/Withdrawn, (4)Restlessness/Pacing/Nervousness, (5)Aggression/Combativeness, (6)Hallucinations/Paranoia/Delusions, (7)Hitting/Kicking/Pinching, (8)Inappropriate behavior, (9)Yelling/Screaming, (10)Wandering, (11)Other every shift for Lorazepam, Quetiapine. Review of Resident #66's MAR for April 2025 reflected he received Quetiapine 25mg each night as ordered. The MAR reflected behaviors were monitored each shift as ordered. From 04/01/25 through 04/15/25 five episodes of Restlessness/Pacing/Nervousness and five episodes of Wandering were document on day shift. Three episodes of Restlessness/Pacing/Nervousness and three episodes of Wandering were document on night shift. No other behaviors were documented. Review of Resident #66's Nursing Home History and Physical, dated 12/11/24, completed by his attending physician, reflected in part, Chief Complaint: New admit to (facility) from hospital d/t Alzheimer's. Medical History: Alzheimer's, cataract-BL, HTN (high blood pressure), joint pain, muscle weakness, BPH (enlarged prostate), microscopic hematuria (blood in the urine), nocturia (waking at night to urinate). CNS: A&O x1 (Central Nervous System: Alert and Oriented to person) Review of Resident #66's Nursing Home Progress Note date 03/19/25, written by the Nurse Practitioner, reflected in part, Medical History/Diagnosis: Alzheimer's, cataract-BL, HTN, joint pain, muscle weakness, BPH, microscopic hematuria, nocturia. New Problems: Wanders and exit seeking, agitation at times. Lorazepam effective. Referral to Psych NP. Review of Resident #66's PASRR Screening dated 01/25/25, reflected a primary diagnosis of dementia and no evidence or an indicator the resident had a mental illness. Review of the Consultant Pharmacist/Physician Communication form, dated 04/01/25, reflected Resident #66 was taking Quetiapine 25mg - Give 1 tablet by mouth at bedtime related to Dementia. During an observation on 04/14/25 at 11:50 AM, revealed Resident #66 made several attempts to open an exit door in the dining room, setting off an alarm, during lunch. Staff stayed with the resident and attempted several times to redirect the resident away from the door. Different staff approached and attempted redirection. Eventually the resident went to the table where his lunch tray had been placed. During an interview on 04/16/25 at 8:42 AM, the ADON stated some residents were admitted to the facility with orders for psychotropic medications. When that happened, they made efforts to get all of the background information that they could. She stated for psychotropic medications, they obtained consents from the RP. She stated all of the psychotropic prn medications were limited to 14 days then reevaluated. She stated they monitored each psychotropic medication for behaviors and side effects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 12 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated she and the DON were responsible for follow up on the pharmacy reviews and recommendations. The ADON stated she had seen a note about Resident #66's Quetiapine in documentation from the hospital prior to his admission at the facility. The documentation was not provided prior to exit from the survey. During a telephone interview on 04/16/25 at 9:14 AM, the Consulting Pharmacist stated she had recently conducted a review of Resident #66's medications. She stated it did not flag for her that Resident #66's Quetiapine was ordered for the diagnosis of dementia. During an interview on 04/16/25 at 2:42 PM, the NC stated anyone on psychotropic medications required an appropriate diagnosis, behavior and side effect monitoring, consent, and a care plan. She stated an assessment was required if the resident did not have a diagnosis. She reviewed Resident #66's medical record and stated she did not find documentation of the rationale for the resident to be taking Quetiapine. She stated the admitting nurse put the physician's orders into the computer and the MDSC reviewed the new orders. She stated the ADON audited and monitored new orders. The NC stated she had reached out to Resident #66's physician who treated him prior to his hospitalization during the survey, to request information about the Quetiapine and any psychiatric diagnoses. She had not received a response prior to exit from the survey. During an interview on 04/16/25 at 2:57 PM, the ED stated he did not want to provide inaccurate information about Resident #66's documentation but he did recall multiple discussions about his psychotropic medications. He reached out to the previous DON who stated they had made changes to the Lorazepam but did not recall any changes to the Quetiapine. Review of the facility's Antipsychotic Medication Use policy, revised December 2016, reflected in part, Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed . Policy Interpretation and Implementation: 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or b. Re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered, or discontinued. c. Based on assessing the resident's symptoms and overall situation, the Physician will determine whether to continue, adjust, or stop existing antipsychotic medication. 6. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. 7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; g. Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., highdose steroids) . 11. Anti psychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; h. Sadness or crying alone that is not related to depression or other psychiatric disorders; i. Fidgeting; j. Nervousness; or k. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 13 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Uncooperativeness. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Use of Psychotropic Medication(s) policy, revised 2025, reflected in part, Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Definitions: Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals .Policy Explanation and Compliance Guidelines: 2. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s ) . 6. Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 14 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: Dietary staff failed to effectively label items in the refrigerator and freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 04/14/2025 beginning at 9:11 am the following was observed: The refrigerator contained what appeared to be green bell peppers, tomatoes, and bananas in a clear plastic bin with no label. The freezer contained what appeared to be cheese sticks in a clear plastic bag with no label. Interview with the Dietary Manager on 04/16/2025 at 11:05 am, the DM stated all items in the refrigerators and freezers should be sealed, labeled, and dated. The DM confirmed that the items not labeled were green bell peppers, tomatoes, bananas, and cheese sticks. The DM stated all items have been thrown away due to them not being labeled. The DM stated she was responsible for ensuring items were labeled and dated. The DM stated if an item was not labeled then someone would not know what the item was. The DM stated if an item was not dated then the item could be spoiled and that could cause residents to get sick. Interview with the ADM on 04/16/2025 at 11:50 am, the ADM stated all items should be sealed, labeled, and dated. The ADM stated that if an item was not labeled then it may not be identified correctly. The ADM stated whoever opened the item would be responsible for ensuring it was sealed, labeled and date properly. Record review of the facility's Food receiving and Storage policy, revised dated October 2017, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 15 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of four residents (Resident #2 and Resident #52) reviewed for infection control. Residents Affected - Few The facility failed to ensure LVN A wore a gown on 04/15/25 when she provided wound care to Resident #2, who was on EBP. The facility failed to ensure CNA D performed hand hygiene when changing gloves on 04/15/25 when she provided incontinent care for Resident #52. These failures could place residents at risk of cross contamination or infection. Findings included: Review of Resident #2's face sheet, dated 04/15/25, reflected an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included other chronic osteomyelitis right ankle and foot (infection of the bone), peripheral vascular disease (disorder of the blood vessels outside of the heart, often decreased blood flow to the limbs), rheumatoid arthritis (a disease that causes inflammation of joints but can affect other organs), chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), and type 2 diabetes mellitus(a condition that affects the way the body processes blood sugar) with foot ulcer (a wound on the foot). Review of Resident #2's significant change in status MDS assessment, dated 03/28/25, Section C reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG reflected he required maximum assistance with bed mobility and was dependent for transfers. Section M reflected Resident #2 had diabetic foot ulcers, received pressure ulcer/injury care, and application of dressings to his feet. Review of Resident #2's Order Summary Report for active orders as of 04/15/25, reflected the following orders 10/02/24 - Enhanced Barrier Precautions (gown and gloves) during high-contact care every shift for wound. 04/15/25 - Right Heel: Cleanse with wound cleanser, pat dry, apply Santyl to wound bed, cover with an island dressing daily. Do not use foam dressing on wound per (wound care doctor). During an observation and interview on 04/15/25 at 11:35 AM revealed LVN A was observed at the treatment cart as she gathered supplies for wound care on Resident #2. LVN A stated the wound care doctor had seen the resident earlier in the morning. LVN A entered Resident #2's room and placed her supplies on the clean table. She retrieved a yellow isolation gown and placed it on the table with the other supplies. She washed her hands and applied clean gloves. She explained to the resident each step of what she did. She positioned the resident and lifted his right leg. She placed a pad under his leg. She removed her gloves and performed hand hygiene. She applied clean gloves. She removed the dressing from the wound on Resident #2's right heel. She removed her gloves, performed hand hygiene, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 16 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and applied clean gloves. She used wound cleanser moistened gauze to clean the wound. She removed her gloves, performed hand hygiene, and applied clean gloves. She patted the wound with dry gauze. LVN A then stated, I blew it already. I forgot to put on my gown. She stated the resident was on EBP because of the wound. She stated anyone with a stage 2 (a shallow open wound on the skin) or higher wound required EBP. She stated EBP required gloves and a gown were worn during wound care. She was observed as she applied the gown then returned to the wound care. She applied the ordered medication to the wound bed then covered the wound with the island dressing as ordered. LVN A stated she had training on EBP, and she trained other staff on infection control. She stated she was just nervous. She stated not following infection control practices could lead to spread of infection. Review of Resident #52's face sheet, dated 04/15/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (dementia that damages the brain), unspecified protein-calorie malnutrition, hypertension (high blood pressure), abnormalities of gait and mobility, and muscle weakness. Review of Resident #52's MDS admission assessment dated [DATE], Section C, reflected a BIMS score of 3 indicating severe cognitive impairment. Section GG reflected she required assistance with toileting hygiene. Section H reflected Resident #52 was incontinent of bladder and bowel. Review of Resident #52's comprehensive care plan created on 03/27/25 did not address her incontinence or ADL assistance required. During an observation and interview on 04/15/25 at 1:47 PM, revealed CNA D and CNA E entered Resident #52's room and washed their hands and applied clean gloves. The CNAs explained the procedure to the resident. CNA D pulled moistened wipes out of the package and placed them on her work surface. She raised the level of the bed and opened the soiled brief. CNA D removed her gloves, and without performing hand hygiene, applied clean gloves. CNA D provided incontinent care to the front of Resident #52 and the CNAs repositioned the resident to her right side. CNA D provide incontinent care to the back side of Resident #52. CNA D removed her gloves and without hand hygiene, applied clean gloves. CNA D applied a new brief. Both CNAs positioned the resident and placed the call light within reach. Both CNAs stated they had received training on infection control and hand washing. CNA E stated hand hygiene was important to prevent the spread of infection. The CNAs stated they were supposed to clean their hands with each glove change. During an interview on 04/16/25 at 8:42 AM, the ADON stated she was the Infection Preventionist. She stated LVN A was the educator, and she was responsible for providing in-service training on infection control. The ADON stated hand washing was performed before and after any procedure and hand hygiene was performed when gloves were changed. She stated in-services on EBP was provided. Staff were required to wear gloves and a gown when they performed high contact care including wound care. She stated not following infection control guidelines could lead to infections or MDROs. During an interview on 04/16/25 at 2:42 PM, the NC stated it was her expectation that infection control guidelines, including EBP were followed. She stated she expected staff to wear a gown and gloves when providing care to resident who required EBP. She stated not following infection control procedures could cause infections. During an interview on 04/16/25 at 2:57 PM, the ED stated he expected staff to practice good infection control and follow the infection control procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 17 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of an in-service dated 11/08/24, reflected LVN A provided training, including Handwashing and Enhanced Barrier Precautions. CNA D and CNA E signed the in-service attendance sheet. Review of the facility's undated Enhanced Barrier Precautions Policy, reflected in part, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) . 3. Implementation of Enhanced Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . 4. High-contact resident care activities include: a. Dressing . h. Wound care: any skin opening requiring a dressing . 10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's undated Hand Hygiene policy, reflected in part, Hand hygiene is the general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub .1. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .6 Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the attached Hand Hygiene Table reflected in part, Before applying and after removing personal protective equipment (PPE), including gloves. The box for Either Soap and Water or Alcohol Based hand rub (ABHR is preferred) is marked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676093 If continuation sheet Page 18 of 18